Healthcare Provider Details

I. General information

NPI: 1316450513
Provider Name (Legal Business Name): HEIDI SUE BISHOP LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2017
Last Update Date: 07/10/2025
Certification Date: 07/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11010 PRAIRIE LAKES DR STE 350
EDEN PRAIRIE MN
55344-3801
US

IV. Provider business mailing address

1479 COLLINS AVE
MARYSVILLE OH
43040-8808
US

V. Phone/Fax

Practice location:
  • Phone: 952-746-2522
  • Fax:
Mailing address:
  • Phone: 937-642-1065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.1600895
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: